Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Challenges in the care of the acutely ill

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

The role of tracheotomy in weaning

Tracheotomy is commonly performed in ventilator-dependent patients. Disadvantages to the procedure are perioperative complications, long-term airway injury, and the cost of the procedure. Benefits ascribed to tracheotomy vs prolonged translaryngeal intubation include improved patient comfort, more effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased potential for speech, ability to eat orally, a more secure airway, accelerated ventilator weaning, reduced ventilator-associated pneumonia, and the ability to transfer ventilator-dependent patients from the ICU. None of these benefits, however, have been demonstrated in large-scale, prospective, randomized studies. It is proposed that there should be an anticipatory approach wherein tracheotomy is considered after an initial period of stabilization with the patient receiving mechanical ventilation when it becomes apparent that the patient will require prolonged ventilator assistance. Tracheotomy then is performed when the patient appears likely to gain one or more of the benefits ascribed to the procedure.

Effects of advance care education in cardiovascular rehabilitation programs: a prospective randomized study

PURPOSE

To determine the effect of advance care education provided to patients enrolled in cardiovascular rehabilitation (CVR) programs and assess patients' acceptance of the educational program.

METHODS

In a multicenter, prospective, randomized study, the authors administered two questionnaires 6 months apart to 284 patients enrolled in 14 CVR programs in 11 states. An educational group (99 subjects) participated in educational programs related to advance care planning and received advance directive forms after completing the first questionnaires; 185 subjects served as controls. Primary outcomes were completion of patient-physician discussions of end-of-life issues and patient confidence that their end-of-life wishes were understood by their physicians. Secondary outcomes were completion of formal advance directives and patient acceptance of the educational program.

RESULTS

Both the educational and control groups demonstrated a larger proportion of patients at the end of the study, compared with the amount at the beginning of the study, who had completed living wills, durable powers of attorney for healthcare, and discussions with their physicians about advance directives and life support care. These outcomes were not observed more commonly after the educational intervention. Neither groups gained confidence, however, that their physicians understood their end-of-life wishes. Only 8.6% of patients had a negative response to the educational program.

CONCLUSIONS

Advance care education is well received by patients enrolled in CVR programs. Enrollment in CVR promotes advance care planning to a small but measurable degree CVR rehabilitation programs appear to be acceptable sites for advance care planning but further research is needed to develop effective educational interventions.

Altering physician behavior to improve clinical performance

Increasing public awareness of the need to improve quality in health care and to limit unexplained variations in clinical practice have promoted interest in altering physician behavior. Unfortunately, many programs for changing the practice patterns of providers have proven less effective than anticipated. Interventions have often been initiated without a clear understanding of their theoretical basis or the empiric data supporting their use. This article reviews the various interventions available for altering physician behavior and their evidence of effectiveness.

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement

OBJECTIVE

Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax.

OPTIONS

Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging.

OUTCOMES

Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence.

EVIDENCE

Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel.

VALUES

The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire.

BENEFITS, HARMS, AND COSTS

The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation.

RECOMMENDATIONS

Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care.

VALIDATION

Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee.

IMPLEMENTATION

The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs.

SPONSORS

The ACCP.

Parapneumonic Effusions and Empyema

Parapneumonic effusions occur in up to 60% of patients hospitalized with community acquired pneumonia. Fortunately, the majority of these effusions follow an uncomplicated course responding to antibiotic therapy alone. An important subgroup of patients, however, follow a complicated course progressing to an empyema unless infected pleural fluid is drained. Decisions for drainage depend on host factors, the nature of the respiratory pathogen, and the extent of pleural inflammation and loculation. Staging of a parapneumonic effusion allows selection of a drainage procedure that will be most effective. Adjunctive therapies, such as intrapleural fibrinolysis, appear to contribute to resolution of pleural infection but more investigational data are needed to determine their specific role.

Transverse myelitis associated with restless legs syndrome and periodic movements of sleep responsive to an oral dopaminergic agent but not to intrathecal baclofen

Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) are related sleep disorders that occur with increased frequency in spinal cord disease. Effective treatment may be obtained with dopaminergic or opioid drugs, while anticonvulsants, benzodiazepines, and possibly baclofen may be helpful. This report describes a patient who developed RLS and PLMD after acute transverse myelitis associated with infectious mononucleosis, and failed to respond to intrathecal baclofen. All symptoms of RLS/PLMD resolved after treatment with pergolide.

End-of-life care preferences of patients enrolled in cardiovascular rehabilitation programs

STUDY OBJECTIVES

The study assessed the interests of ambulatory cardiac patients in advance planning and their willingness to participate in rehabilitation program-based end-of-life education.

DESIGN

Observational survey study.

SETTING

Fourteen outpatient cardiac rehabilitation programs in 11 states.

PARTICIPANTS

Four hundred fifteen subjects enrolled in cardiac rehabilitation.

MEASUREMENTS AND RESULTS

A questionnaire determined patient preferences for advance planning, completion of advance directives, completion of patient-physician discussions on end-of-life care, and effects of health status on patient acceptance of life-sustaining interventions. Seventy-two percent of patients wanted to direct their own end-of-life care, 86% desired more information on advance directives, 62% wanted to learn about life-sustaining care, and 96% were receptive to advance-planning discussions with their physicians. Seventy-two percent of patients had considered that they might require life-sustaining care in the future; acceptability of resuscitative care depended on health status and probability of survival. However, only 15% had discussed advance planning with their physicians, and 10% were confident that their physicians understood their end-of-life wishes. Physicians and cardiovascular rehabilitation programs were considered desirable sources of information on advance planning.

CONCLUSIONS

Cardiac patients enrolled in rehabilitation programs want to learn more about end-of-life care and need more opportunities to discuss advance planning with their physicians. Patients consider cardiovascular rehabilitation programs to be acceptable sites for advance planning education.

Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data

STUDY OBJECTIVES

To determine the predictive accuracy of pH for identifying patients with malignant pleural effusions who will fail pleurodesis.

DESIGN

Analysis of published and unpublished individual patient-level data retrieved from a MEDLINE search and correspondence with primary investigators.

STUDY SELECTION

Studies that reported pleural fluid pH values and outcomes of pleurodesis for patients with malignant pleural effusions.

DATA COLLECTION AND ANALYSIS

Primary investigators supplied data for 433 patients. Receiver operating characteristic analysis and logistic regression estimated the predictive accuracy, decision thresholds, and value of pleural fluid pH compared with other clinical factors. The primary investigations were graded for study design.

RESULTS

Pleural fluid pH was the only independent predictor of pleurodesis failure (odds ratio, 4.46; 95% confidence interval [CI], 2.69 to 7.45; p < 0.0001) and had an area under the receiver operating characteristic curve (decision threshold, < or = 7.28) of 0.671 (95% CI, 0.624 to 0.715). The pH model fit the data well (p = 0.48) with the probability of pleurodesis failure increasing as pH decreased; specificity and negative predictive values for pleurodesis failure exceeded 90% and 80%, respectively, with a positive predictive value of 45.7% at pH values < or = 7.15. The primary studies had several important design limitations.

CONCLUSIONS

Using patient-level data, this study showed that pleural fluid pH has only modest predictive value for predicting symptomatic failure and should be used with caution, if at all, in selecting patients for pleurodesis. The limitations of the primary studies and low predictive accuracy should be considered when using pleural fluid pH for patient care.

Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions

STUDY OBJECTIVES

To assess the accuracy of pleural fluid (PF) pH in predicting duration of survival of patients with malignant pleural effusions.

DESIGN

Analysis of patient-level data from nine sources retrieved from a MEDLINE search and correspondence with primary investigators.

STUDY SELECTION

Published and unpublished studies that report PF pH values and duration of survival of patients with malignant pleural effusions.

DATA COLLECTION AND ANALYSIS

Primary investigators supplied patient-level data (n = 417), which was examined by receiver operating characteristic (ROC) analysis, logistic regression, and survival time modeling to determine the utility of PF pH for predicting survival compared with other clinical factors. The primary investigations were graded for study design.

MEASUREMENTS AND RESULTS

Median survival (n = 417) was 4.0 months: PF pH (p < 0.0039) was an independent predictor of survival duration. A PF pH test threshold < or = 7.28 had the highest accuracy for identifying poor 1-, 2-, and 3-month survivals. The predictive accuracies of PF pH (area under the ROC curve range, 0.571 to 0.662) and a PF pH-high-risk tumor (lung, soft tissues, renal, ovary, gastrointestinal, prostate, and oropharynx) model (odds ratio range, 2.91 to 6.67), however, were modest for predicting 1-, 2-, and 3-month survival. Only 54.4% and 62.7% of patients identified by PF pH < or = 7.28 or the PF pH-high-risk tumor model to die within 3 months were correctly classified. Weaknesses of the primary data were identified.

CONCLUSIONS

PF pH has insufficient predictive accuracy for selecting patients for pleurodesis on the basis of estimated survival.

Infection of the pleural space

Parapneumonic effusions are common accompaniments of pneumonia that require proper management to prevent progression to empyema. Management decisions require thoughtful individualization of care because of the multiple factors that affect outcome; no one algorithmic approach exists for all patients. Basic principles of care, however, apply to all patients and center on the early detection of infected pleural fluid and the rapid completion of effective pleural drainage and lung re-expansion, when indicated to decrease morbidity and mortality.

Indications for draining a parapneumonic effusion: an evidence-based approach

A patient with pneumonia who develops a parapneumonic effusion challenges the physician to determine the need for pleural fluid drainage. This determination is influenced by multiple factors including the patient's general state of health, the existence of comorbidities, the virulence of the underlying pathogen, and the extent of the pneumonia that dictate clinical outcome and the relative risks and benefits of drainage. The presence of intrapleural pus represents the only factor that clearly establishes the need for drainage, although most experts recommend draining pleural fluid that is positive by Gram's stain or culture for a pathogen. Other factors such as the extent of the patient's pneumonia, severity of systemic signs of inflammation, radiographic features of the effusion, and pleural fluid chemical profile assist clinical decision making. The fundamental principle that guides therapy is the need to promptly and effectively drain pleural fluid whenever it appears likely that it will progress to a frank empyema with antibiotic therapy alone.

Compliance with do-not-resuscitate orders for hospitalized patients transported to radiology departments

BACKGROUND

Little is known about the effectiveness of do-not-resuscitate (DNR) orders during transport of hospitalized patients away from their rooms.

OBJECTIVE

To determine compliance with DNR orders in radiology departments.

DESIGN

Observational study.

SETTING

248 hospital-based radiology departments.

PARTICIPANTS

248 radiology department representatives.

MEASUREMENTS

10-item questionnaire examining the response of radiology personnel to patients with DNR orders who experience cardiopulmonary arrest.

RESULTS

Written DNR protocols and structured procedures for communicating DNR status were used by 18.5% (CI, 13.7% to 23.4%) and 18.1% (CI, 13.3% to 23.0%) of departments, respectively. Medical chart review was the only source of information on DNR status for 41.5% (CI, 35.4% to 47.7%) of departments. It was found that 20.2% of respondents (CI, 15.2% to 25.2%) would resuscitate patients with DNR orders and that 38.3% (CI, 32.3% to 44.4%) had resuscitated patients with DNR orders in the past.

CONCLUSIONS

Most radiology departments do not have formal procedures to prevent patients from undergoing unwanted or inappropriate resuscitative interventions, and DNR orders are frequently overruled.

MRI of central venous anatomy: implications for central venous catheter insertion

STUDY OBJECTIVES

To determine normative values for superior vena cava (SVC) length and the utility of radiographic landmarks for identifying the boundaries of the SVC for assisting central line placement.

DESIGN

Cross-sectional study.

SETTING

Urban tertiary care medical centers.

PATIENTS

Patients undergoing thoracic MRI scanning for various indications.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The SVC dimensions and relationship to radiographic landmarks were determined from MRI scans of 42 patients (22 men, 20 women; median age, 57 years). The median length of the SVC was 6.8 cm (range, 4.4 to 10.0 cm) and did not correlate with gender or other measured cardiovascular dimensions. The right tracheobronchial angle was the best radiographic landmark for determining the cephalad origin of the SVC being always caudad and within a median of 1.5 cm (range, 0.1 to 3.8 cm) of the upper SVC. It was always at least 2.9 cm above the atriocaval junction. The right superior heart border was formed by the left atrium in 38% (95% confidence interval, 23 to 53%) of patients and did not reliably identify the atriocaval junction.

CONCLUSIONS

The right tracheobronchial angle is the most reliable landmark for the upper margin of the SVC. Venous catheters placed caudad to this landmark and cephalad to the right superior cardiac silhouette or no more than 2.9 cm caudad to the tracheobronchial angle result in catheter tips within the SVC.

End-of-life ethical issues

COPD is a progressive disorder characterized by intermittent episodes of acute exacerbations, each of which has the potential for producing respiratory failure and a need for mechanical ventilation. The decision to intubate a patient with severe underlying COPD requires a blending of the physician's estimation of prognosis with the patient's life goals, values, and self-perceived quality of life. Decisions regarding intubation and life support are aided by initiating a patient-caregiver dialogue during periods of good or stable health before a medical crisis occurs. These discussions can inform patients about the likely outcome of life support and promote meaningful and valid advance directives.

Methodologic standards for diagnostic test research in pulmonary medicine

STUDY OBJECTIVES

To determine conformance with methodologic standards in the evaluation of diagnostic tests.

DATA SOURCES

MEDLINE database search (1992 to 1997) of nine prominent general medicine and six subspecialty journals for articles that report discriminative properties of diagnostic tests in pulmonary medicine.

STUDY SELECTION

Articles were eligible if they reported discriminative properties of diagnostic tests in humans, diagnostic tests were intended for the detection of existing conditions, and the target disorder was relevant to pulmonary medicine.

DATA EXTRACTION

Each study was critically reviewed independently by two observers.

DATA SYNTHESIS

Of the 1,029 retrieved articles, 41 met study inclusion criteria. The median number of the 12 major standards for design fulfilled by study articles was 6 (range, 1 to 12, 25th to 75th percentile, 5.0 to 8.5) and only 2 articles fulfilled all 12 standards. Seven (17%) articles did not report any standard measures of diagnostic accuracy and 7 (17%) provided data only for sensitivity and specificity. Only 4 of 17 articles (24%) that compared different tests used standard statistical methods.

CONCLUSION

These results indicate that greater methodologic rigor is needed for studies that evaluate diagnostic tests in pulmonary medicine. Existing deficiencies in methodology risk the introduction of invalid tests into clinical practice.

Evaluating diagnostic tests in the pleural space. Differentiating transudates from exudates as a model

Physicians have a staggering variety of diagnostic tests available for directing their diagnostic and therapeutic decisions. Technologic advances in laboratory science have increased the sophistication of new tests and accelerated their rate of adoption into clinical practice. Unfortunately, studies that report the value of new diagnostic tests often fail to follow accepted methodologic standards for unbiased test assessment or provide clinicians with sufficient information for the intelligent evaluation of a test's performance and applicability. The following review of pleural fluid tests that discriminate between exudative and transudative effusions serves to highlight important methodologic considerations in the assessment of diagnostic tests.

Communicating do-not-resuscitate orders with a computer-based system

BACKGROUND

Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form.

METHODS

Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld.

RESULTS

For the 147 patients, the computer-based system in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was "substantial" or "almost perfect" as measured by the K statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff.

CONCLUSION

A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.

Does evidence-based medicine help the development of clinical practice guidelines?

Formal methods for the development of clinical practice guidelines have emerged to address societal needs to decrease physician practice variation, slow the rise of health-care costs, monitor inappropriate care, assist clinicians to stay abreast of new clinical information, set research priorities, and promote better health-care outcomes. Evidence-based methods ensure that guidelines provide valid recommendations based on a critical appraisal of the best available evidence rather than informal, opinion-based processes.

Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators

STUDY OBJECTIVE

To (1) determine appropriate decision thresholds and diagnostic accuracies for pleural fluid (PF) tests that discriminate between exudative and transudative pleural effusions, and (2) evaluate the quality of the primary investigations.

DESIGN

Formal meta-analysis of studies that report the diagnostic value of pleural fluid tests.

SETTING

Data collected from international academic medical centers.

PATIENTS

Hospitalized patients undergoing thoracentesis for pleural effusions.

INTERVENTIONS

Primary investigators were requested to transmit original data from patients described in their studies.

MEASUREMENTS AND RESULTS

Eight primary studies described 1,448 patients with one or more of the following tests: protein (P)-PF, P-PF/serum ratio (R), bilirubin (BILI)-R, lactate dehydrogenase (LDH)-PF, LDH-R, cholesterol (C)-PF, C-R, and albumin gradient. We found that all eight tests had similar diagnostic accuracies when evaluated by receiver operating characteristic (ROC) analysis except for BILI-R, which was less diagnostically accurate. Decision thresholds determined by ROC analysis differed from previously reported values for LDH-PF (>0.45 upper limits of normal) and C-PF (>45 mg/dL). Paired and triplet test combinations tended to have higher diagnostic accuracies compared with individual tests, but examination of the odds ratios with 95% confidence intervals did not identify a clearly superior test combination. Limitations of the primary studies presented a high likelihood of bias affecting their results.

CONCLUSIONS

Several strategies exist for clinicians in utilizing PF tests to classify effusions as exudates or transudates but accurate interpretations of these test results will require better designed studies.

Publications in subspecialty journals on end-of-life ethics

BACKGROUND

Factors that impede patient adoption of advance directives and inhibit physician-patient discussions about end-of-life issues remain incompletely defined. Determination of publication rates of articles on end-of-life ethics in different subspecialty journals may provide insight into physicians' reluctance to promote advance directives for their patients, which appears to vary between subspecialty fields.

OBJECTIVE

To determine publication rates of items on end-of-life issues and other ethics topics.

METHODS

We surveyed core journals from 1976 to 1995 in cardiology (n = 5), critical care medicine (n = 1), nephrology (n = 4), oncology (n = 7), and pulmonary medicine (n = 2).

RESULTS

Critical care medicine (50.4%; 95% confidence interval [CI], 45.0%-55.8%) and pulmonary medicine (27.6%; 95% CI, 22.7%-32.5%) journals published considerably more articles on end-of-life issues than journals in cardiology (4.1%; 95% CI, 0.8%-7.4%), nephrology (11.0%; 95% CI, 7.9%-14.1%), or oncology (6.9%; 95% CI, 1.5%-12.3%). Oncology (30.7%; 95% CI, 25.3%-36.1%), critical care medicine (29.6%; 95% CI, 24.2%-35.0%), and pulmonary medicine (21.5%; 95% CI, 16.6%-26.4%) journals published more items pertaining to all ethics-related topics compared with cardiology (11.0%; 95% CI, 7.3%-14.7%) or nephrology (7.3%; 95% CI, 4.2%-10.4%) journals. Oncology journal ethics articles most often pertained to informed consent or research issues.

CONCLUSIONS

Different internal medicine subspecialty fields demonstrate markedly different patterns of publishing items on topics pertaining to end-of-life issues.

Outcomes of advance directive education of pulmonary rehabilitation patients

We performed a two-site prospective, controlled interventional study of patients enrolled in pulmonary rehabilitation to assess effects of advance directive education on completion of (1) living wills, (2) durable powers of attorney for health care (DPAHC), (3) patient-physician discussions about advance directives, and (4) discussions about life support, in addition to (5) patient impressions that their physicians understood their end-of-life preferences. The educational group had an increase (p < 0.05) in all five study outcomes compared with baseline values; the control group had an increase in three of five outcomes. The effect strength was greater in the educational compared with the control group for completion of DPAHC (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.1 to 12.9), advance directive discussions (OR = 2.9, 95% CI 1.1 to 8.3), initiation of life-support discussions (OR = 2.7, 95% CI 1.0 to 7.7), and development of patient assurance that their physicians understand their preferences (OR = 3.7, 95% CI 1.3 to 13.4). The educational intervention was an independent explanatory factor by multivariate analysis. We conclude that patients enrolled in pulmonary rehabilitation are receptive to advance care planning, which is promoted by education on end-of-life issues.

Attitudes regarding advance directives among patients in pulmonary rehabilitation

We performed a cross-sectional, descriptive questionnaire study in two pulmonary rehabilitation programs to assess: (1) attitudes of 105 subjects with chronic lung conditions about end-of-life decision-making; (2) the determinants of these attitudes; and (3) patient acceptance of rehabilitation programs as foci for education about advance directives (ADs). We found that 99 of the 105 subjects (94.3%) had health worries, the most common of which was fear of increasing dyspnea (33.3%). Although 93.8% had opinions about intubation, less than 42% had completed an AD. Most subjects wanted information about ADs (88.6%) and life-support (68.6%); pulmonary rehabilitation programs, lawyers, and physicians were preferred sources for AD information. Although 98.9% of the patients wanted patient-physician AD discussions, only 19.0% had such discussions, only 15.2% had discussed life-support, and only 14.3% thought that their physicians understood their end-of-life wishes. Subject willingness to undergo intubation varied with baseline health, likelihood of survival, and anticipated health following extubation. We conclude that patients in pulmonary rehabilitation programs desire more information about end-of-life issues than is currently provided by physicians. They regard pulmonary rehabilitation educators as valuable sources of AD education.

Platelets attenuate oxidant-induced permeability in endothelial monolayers: glutathione-dependent mechanisms

We studied the effects of adding washed human platelets or platelets with nonintact glutathione redox cycles to endothelial cell monolayers treated with glucose oxidase to initiate oxidant stress and increase permeability. Changes in 125I-labeled albumin transmonolayer movement were used as the index of monolayer permeability. Washed human platelets attenuated oxidant-induced increases in albumin flux. Platelets treated with 1,3-bis(2-chloroethyl)-1-nitrosurea, 1-chloro-2,4-dinitrobenzene, or buthionine sulfoximine to inhibit selective enzymatic steps in the glutathione redox cycle decreased permeability to a lesser degree. We conclude that 1) washed human platelets attenuate monolayer permeability defects in aortic endothelial monolayers exposed to glucose oxidase and 2) the protective effects of platelets are partially dependent on an intact platelet glutathione redox cycle.

Utility of routine admission chest radiographs in patients with acute gastrointestinal hemorrhage admitted to an intensive care unit

PURPOSE

To determine the diagnostic yield of routine admission chest radiographs in patients with acute gastrointestinal (GI) hemorrhage and clinical predictors of radiographic abnormalities.

PATIENTS AND METHODS

The study was a retrospective series of 202 adult patients with GI hemorrhage admitted to intensive care units at an academic medical center. Routine admission chest radiographs were obtained in 161 patients. These radiographs were reviewed by a study radiologist blinded to the study purpose. The radiologist scored radiographic abnormalities into categories of "minor" or "major," "new" or "previously known," and "with an intervention" or "without an intervention." Nominal logistic regression explored the data for clinical features that identified patients with major new radiographic abnormalities with or without an intervention.

RESULTS

Minor radiographic abnormalities were noted in 23 (14.3%) patients, of whom 17 (10.6%) patients had "new" (previously unknown) abnormalities. No minor abnormality prompted a therapeutic or diagnostic intervention. Major radiographic abnormalities were detected in 21 (13.0%) patients, of whom 19 (11.8%) had new findings. Major new findings prompted interventions in only 9 (5.6%) of patients. A history of lung disease and an abnormal lung physical examination predicted major new radiographic findings (P = 0.0001, sensitivity 79%, negative predictive value 96%). These variables also identified major new abnormalities that prompted interventions (P = 0.007, sensitivity 89%, negative predictive value 99%). Use of the logistic regression model to select patients for admission chest radiographs decreased charges from $1,068 to $580 for each detected major new radiographic abnormality and from $2,254 to $1,087 for major new radiographic abnormalities that prompted an intervention.

CONCLUSION

These data indicate that routine chest radiographs have a low yield in detecting major new radiographic abnormalities in patients with acute GI hemorrhage. Clinical criteria, available at the time of admission, may be useful for selecting patients for chest radiographic evaluations.

Involvement of cardiovascular rehabilitation programs in advance directive education

BACKGROUND

Cardiac rehabilitation programs represent opportunities to educate patients with cardiac disease about living wills and durable powers of attorney for health care. The extent of advance directive education that is currently provided in cardiac rehabilitation programs, however, is unknown.

METHODS

A questionnaire was mailed to nonphysician directors of cardiac rehabilitation programs to determine the programs' involvement in educating enrollees about end-of-life issues and the directors' opinions regarding the appropriateness of such education in cardiac rehabilitation curricula. Data were presented as proportions with 95% confidence intervals (Cls).

RESULTS

Of the 1013 cardiac rehabilitation program directors, 845 (83%) responded to the questionnaire, of which 48 stated they were no longer enrolling patients. Of the remaining 797 program directors (83%), 71% (95% CI, 67%-74%) informed patients of their prognosis, but only 18% (95% CI, 15%-20%) and 12% (95% CI, 9%-14%) asked patients if they had a living will or a durable power of attorney for health care, respectively. Only 9% (95% CI, 7%-11%) offered educational sessions on advance directives and 17% distributed advance directive informational material. Education about cardiopulmonary resuscitation was provided by 27% (95% CI, 23%-30%), but only 3% (95% CI, 2%-4%) provided information on do-not-resuscitate topics. Fifty percent (95% CI, 46%-53%) were in favor of including advance directive education and 49% (95% CI, 45%-52%) favored inclusion of do-not-resuscitate topics into curricula.

CONCLUSIONS

Cardiac rehabilitation programs are potentially valuable but not widely used sites for educating patients with cardiac disease about advance directives.

Diagnosis and management of thoracic empyemas

Parapneumonic effusions are frequent complications of bacterial pneumonia. Depending on the severity of the underlying pneumonia, the promptness of antibiotic therapy, and the virulence of the infecting organism, 5% to 50% of patients will require pleural fluid drainage to prevent progression to an empyema. The decision to drain the pleural space depends on multiple clinical, laboratory, and radiographic factors. Delayed drainage results in pleural loculations, prolonged hospitalizations, and increased mortality. Image-guided percutaneous chest catheters provided an effective method for draining both free-flowing and loculated effusions. Fibrinolytic agents are gaining wider acceptance for promoting drainage of loculated, viscous pleural fluid although randomized studies do not exist. Patients failing a chest tube drainage method should undergo early evaluation for an open surgical procedure.

Procedure-specific do-not-resuscitate orders. Effect on communication of treatment limitations

BACKGROUND

Do-not-resuscitate (DNR) orders are often inaccurately communicated between physicians and nurses or residents. Structured, procedure-specific DNR order forms have been suggested to improve communication, but no data exist to support this impression.

METHODS

The level of agreement between attending physicians and nurses or residents in their understanding of the DNR orders of critically ill patients was measured before and after instituting a structured DNR order form. Caregivers were asked (1) about the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. Results were reported as kappa +/- SE.

RESULTS

Nurses (n=41) and residents (n=34) showed only fair to moderate agreement with attending physicians (n=53) for the 76 evaluable patients before initiation of the DNR order form. After initiation of the structured DNR order form, nurses showed higher levels of agreement for the second (0.67 +/- 0.14) and third (0.69 +/- 0.13) components but not the first (0.39 +/- 0.15) component of the DNR order. Residents showed higher levels of agreement for the second (0.90 +/- 0.10) and third components (0.81 +/- 0.13) but not the first (0.57 +/- 0.17) component. Nurses compared with residents had lower levels of agreement with attending physicians for most aspects of the DNR order.

CONCLUSION

A structured DNR order form improves agreement in understanding of some but not all components of the DNR order.

Advance directive education during pulmonary rehabilitation

We conducted a questionnaire survey of 346 pulmonary rehabilitation programs to determine the present utilization and potential value of these sites for promoting advance directive education for patients with chronic lung diseases. Responses were analyzed for all responding programs and for programs categorized by size. Eighty-two percent of the 218 responding programs discussed with patients prognostic information. Only 33% of programs asked patients if they had advance directives and 17% kept these documents on file. Thirty-three percent of programs provided some form of advance directive education, and 42% distributed directive educational material, usually through informal and unstructured methods. Seventy-seven percent of responders considered pulmonary rehabilitation an appropriate site for directive education, and 86% indicated willingness to incorporate directive education into their programs. Larger programs were more likely to present information about patient prognosis (p = 0.0003) and advance directives (p = 0.021). We conclude that most of the responding pulmonary rehabilitation programs do not educate patients about advance directives but are willing to do so if supplied with appropriate teaching materials. Rehabilitation programs may be valuable sites for educating patients with chronic disorders about advance directives and promoting an improved patient-physician dialogue about these issues.

Prospective validation of an acute respiratory distress syndrome predictive score

We derived an Acute Respiratory Distress Syndrome Score (ARDS Score) from previously described training set data. To validate its diagnostic accuracy for identifying a complicated course (early death or prolonged intubation) in acute lung injury, 50 patients were prospectively scored using an ARDS Score decision threshold of > or = 2.5 to discriminate between an uncomplicated (successful extubation after < or = 14 d) and complicated course. Predictor factors incorporated in the ARDS Score were collected on Day 4 and Day 7 of ARDS and included PaO2/PAO2 ratio, required positive end-expiratory pressure (PEEP), and chest radiograph progression. The diagnostic accuracy of the ARDS Score for determining a complicated course as well as overall survival was compared with three other available indices. Using receiver operating characteristic (ROC) analysis, the ARDS Score and Lung Injury Score (LIS) had the greatest diagnostic accuracy for determining a complicated course, but the Simplified Acute Physiology Score (SAPS Score) (score > or = 14) more accurately identified survival. The LIS components of static respiratory system compliance (Crs) and chest radiograph description did not differ between patient groups. The interobserver concordance of the dynamic chest radiograph interpretation included in the ARDS Score was significant (p < 0.05). We conclude that the previously derived ARDS Score has valid diagnostic accuracy for identifying patients with ARDS who will follow a complicated course.

Recurrent pneumothoraces in ventilated patients despite ipsilateral chest tubes

The incidence of recurrent pneumothoraces was analyzed in mechanically ventilated patients with the adult respiratory distress syndrome (ARDS) or non-ARDS causes of respiratory failure who had ipsilateral chest tubes in place. The radiographs of 39 consecutive patients with 47 initial pneumothoraces were evaluated for pneumothorax recurrence and chest tube positioning, which was prospectively defined as having a "vertical" or "horizontal" orientation. "Horizontal" positioning indicated that the chest tube may have been placed into a major fissure or the posterior hemithorax. Sixteen of the 47 pneumothoraces in all study patients, 14 of the 21 pneumothoraces in patients with ARDS, and 2 of the 26 pneumothoraces in patients without ARDS recurred (p < 0.0001) despite an ipsilateral chest tube; 9 of the 14 ARDS pneumothorax recurrences were tension types. "Horizontal" chest tube positioning in patients with ARDS had a positive predictive value of 86% and 64% for recurrences of pneumothoraces and tension pneumothoraces, respectively. Recurrent pneumothoraces occur commonly in mechanically ventilated patients with ARDS despite ipsilateral chest tubes. Because pneumothorax recurrences appear to be related to horizontal chest tube placement, imaging studies should verify that chest tubes are placed in optimally in the anterior hemithorax away from interlobar fissures in this patient population.